A 10-point preoperative checklist: selecting patients for outpatient joint replacement surgery

Background With advancements in perioperative care, joint replacement (JR) surgery is undergoing a transition from opacified in-patient institutions to nimble out-patient Ambulatory Surgical Centers (ASC). The goal of JR in ASC setting is safe patient discharge with subsequent rehabilitation without readmission. Multi-modal preoperative rehabilitation (MMPR) is a novel field of perioperative care, encompassing comprehensive parameters to ensure smooth transition from fitness for surgery to JR in outpatient setting. At present, there are no open-access schemes for selecting patients qualified for JR in the ASC setting. In this article, we propose an evidence-based, 10-point systematic evaluation of patients with target endpoints for MMPR to qualify patients for JR as an outpatient procedure. This checklist is a non-proprietary scheme serving as an initial framework for surgeons exploring surgery in the ASC setting. Body We introduce factors for a prehabilitation scheme, called Checklist Outpatient-Joint Replacement (CO-JR) to qualify patients for outpatient JR surgery. These factors have been developed based on an extensive literature review and the significant experience of authors to incorporate variables that drive a successful outpatient JR procedure. The factors include patient education, psychiatric & cognitive ability, medical fitness, musculoskeletal capability, financial ability, transportation access, patient motivation, information technology (IT) capabilities, along with ability to recover independently at home postoperatively. The CO-JR scheme is under the process of validation at multiple institutions. We introduce this as a starting point for collaborative development of an open-access scheme for all surgeons to learn and adapt as needed for their respective global region. Conclusion We established a non-proprietary 10-point CO-JR scheme, serving as a framework for surgeons to successfully select patients for JR surgery in the ASC setting. We encourage concomitant validation of this scheme globally. Our goal is to reach an international consensus on an open-access scheme, available for all surgeons to enrol patients for JR in the ASC setting, but modifiable to accommodate regional needs.

Traditional preoperative care in JR involves education regarding surgical logistics and medical clearance.These discussions are generic and not patient-tailored.In contrast, MMPR encompasses comprehensive parameters to ensure that the patient will be fit to undergo JR in the outpatient setting.The goal of JR in the ASC setting is safe discharge and subsequent rehabilitation without readmission.MMPR scheme identifies parameters that require optimization.These include lifestyle modifications, optimization of medical comorbidities, patient education in the surgical process, psychological conditioning, physiotherapy and nutrition [17,18].The scheme is personalized for each patient to ensure a safe procedure and recovery in an ambulatory setting.It offers benefits to patients as well as the healthcare systems in efficiency of care.For patients, prehabilitation aims to improve postoperative functional outcomes and reduce the need for ancillary resources.For the healthcare system, prehabilitation offers a better delivery of value-based care by allowing for ambulatory discharge to home and completion of rehabilitation in an outpatient setting.
At present, there are no comprehensive, open-access schemes for selecting patients qualified for JR in the ASC setting.This article proposes a 10-point systematic evaluation of patients with target endpoints for MMPR to qualify patients for JR as an outpatient procedure.This checklist is a non-proprietary scheme, which we would like to be modifiable, to address differences in regional needs.Table 1 outlines our proposed Checklist Outpatient-Joint Replacement (CO-JR), qualifying patients for hip and knee replacement surgery in the ambulatory setting.The score range is from 0 to 10.To be qualified for outpatient JR surgery, we believe patients should have a score > 8, with a mandatory score of 1 (Yes) on Factors 1, 3, and 4.These factors were developed based on an extensive literature review and significant experience to incorporate all factors that drive a successful outpatient JR procedure.The factors include patient education, psychiatric and cognitive ability, medical fitness, musculoskeletal capability, financial ability, transportation access, patient motivation, information technology (IT) capabilities, along with ability to recover independently at home postoperatively (Tables 1 and 2).
One specific area in MMPR that we wish to emphasize is preoperative musculoskeletal training, which is in debate.The assumption is that preoperative musculoskeletal training will confer better postoperative recovery.Training methods include muscle resistance exercises, joint flexibility and step training [40].The duration as well as frequency varies.However, in recent North American hip and knee national meetings, experts raised concerns regarding overzealous preoperative musculoskeletal training, which can cause polyarticular joint inflammation and excess musculoskeletal pain.Preoperative edema and pain adversely affect postoperative recovery.Hence, we recommend emphasis on keeping the joint "calm" and focusing on balance and gait training.
We acknowledge the 10-point CO-JR scoring system is yet to be validated in clinical trials.However, we introduced this as a starting point for the collaborative development of an open-access scheme for all surgeons to learn and adapt as needed for their respective global regions.Our future goal is to validate the scheme locally, but we encourage concomitant validation at other global centers.The goal is to continuously modify this scheme to maximize the outcomes for the ASC setting.We encourage input from all disciplines that interact with patient care in the ASC setting (nursing care, counsellors, physical/occupational therapists, psychiatrists/psychologists, primary care physicians, and orthopaedists).

Conclusion
Our goal is to develop a non-proprietary, open access 10-point CO-JR scheme, developed by the collaborative effort of surgeons across the world, serving as a framework for successfully selecting patients for JR surgery in the ASC setting.We acknowledge that the needs of global populations vary, and the available medical resources are not alike.In the future, we envision a Modified CO-JR for various countries requiring different needs suiting their local ethnic and demographic variances, e.g., Modified CO-JR India, Modified CO-JR Nigeria, Modified CO-JR New Zealand, Modified CO-JR USA etc.The proposed scheme is  [19,20], perception of illness (illness coherence) [21] and expectations of 24-h discharge following surgery [22][23][24] Video tutorials or telemedicine class Final coordinator interview/1-on-1 session with patient Yes = 1 No = 0

Patient Motivation
Patient acknowledges the need for self-improvement and commitment to rehabilitation.The goal is to return to independent living [25][26][27] Patient articulates willingness to participate in Outpatient surgery protocol [23] Reading a standardized script and assessing willingness to participate via a 10-point Modified Likert Scale (with 0 = unmotivated, unwilling and 10 = highly motivated, highly willing).A score of ≥ 5 would be sufficient to proceed with the surgery [26] Yes = 1 No = 0

Medical Fitness, Habits, Nutrition
Optimization of all medical comorbidities [28,29] Normal albumin [30][31][32][33]  In the future, we would encourage an in-person consensus meeting to further expand this grading system.

Table 1
Proposed 10-point checklist for surgeons to enrol patients for joint replacement surgery in an outpatient setting

Table 1 (continued) Checklist Outpatient-Joint Replacement (CO-JR) No Parameter Optimal Value Assessment Instruments
Score > 8 required to qualify for JR in ASC aimed to serve as a benchmark and is currently under the process of validation.With this initial proposal, we encourage concomitant input and validation to create a common, global platform for JR in the ASC setting.

Table 2
Chowdhry-McPherson Test (CMT) for preoperative musculoskeletal capability assessment in joint replacement surgery a Testing is in validation at the present time The patient must be able to get out of bed, onto & out of the toilet, and into & out of the couch at home without becoming encumbered Test Description: 1. Patient sits on a chair with knees at 90 degrees, feet flat on the floor.The chair should have no side arms 2. The patient is asked to perform repetitive sit-to-stand as many times as possible in 30 s.The patient is timed by the examiner 3. A passing grade is ≥ 7 repetitions/30 s